Effective Date: April 14, 2003

Solutions Outpatient Services respects the privacy of personal information and understands the importance of keeping this information confidential and secure. This Notice describes how we protect the confidentiality of the personal information we receive. Our practices apply to current and former clients.

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Understanding Your Health Record/Information

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

  basis for planning your care and treatment 
  means of communication among the many health professionals who contribute to your care 
  legal document describing the care you received 
  means by which you or a third-party payer can verify that services billed were actually provided 
  a tool in educating heath professionals 
  a source of data for medical research 
  a source of information for public health officials charged with improving the health of the nation 
  a source of data for facility planning and marketing 
  a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve 

Understanding what is in your record and how your health information is used helps you to: 

  ensure its accuracy 
  better understand who, what, when, where, and why others may access your health information
  make more informed decisions when authorizing disclosure to others 

Confidentiality of Alcohol and Drug Abuse Client Records

The confidentiality of alcohol and drug abuse client records maintained by Solutions Outpatient Services ("Solutions") is protected by federal law and regulations. Generally, Solutions may not say to a person outside the program that a client attends the program, or disclose any information identifying a client as an alcohol or drug abuser unless one of the following conditions is met:

   the disclosure is allowed by a court order,
   the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation, or
   violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.

Federal law and regulations do not protect any information about a crime committed by a client either at Solutions or against any person who works for Solutions or about any threat to commit such a crime.

Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

Your Health Information Rights

Although your health record is the physical property of Solutions Outpatient Services ("Solutions"), the facility that compiled it, the information belongs to you.

   You may request restrictions on how your information will be used and disclosed for treatment, payment, and health care operations; Solutions is not required to agree to the proposed restrictions.
   Solutions must permit and accommodate reasonable requests for you to receive communications by alternative means or at an alternative location.
   You have the right to inspect and obtain a copy of your health record with very limited exceptions (as provided for in 45 CFR 164.524.) by submitting a written request to the Privacy Officer, Lois Jordan. Access or denial will be provided within 30 days.
   You may also request to have the information amended (as provided in 45 CFR 164.528.) Solutions may deny the request if the information is complete and accurate or was created by another entity.
   Upon request, Solutions must give you a written accounting of all non-routine disclosures made without your consent for up to six years. The first list you request within a 12-month period will be free. Additional lists, we may charge you $.25 per page.
   You may revoke your authorization to Solutions to use or disclose health information except to the extent that action has already been taken 

Solutions' Responsibilities

Solutions is required to:

   maintain the privacy of your health information 
   provide you with a written notice of the uses and disclosures of protected health information (PHI) and your rights and Solutions' legal duties related to PHI
   insure that the notice includes a summary of 42 CFR and the elements required by 42 CFR and HIPAA
   insure that the notice is provided on the first date of service delivery and posted at the site
   maintain copies of notices and comply with requirements relating to revisions
   except in emergencies, Solutions must obtain written acknowledgment of receipt or document good faith effort and reason acknowledgment was not obtained
   abide by the terms of this notice 
   notify you if we are unable to agree to a requested restriction 
   accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you've supplied us.

We will not use or disclose your health information without your authorization, except as described in this notice.

For More Information or to Report a Problem

If have questions and would like additional information, you may contact the Privacy Officer, Lois Jordan, at 214-369-1155. 

If you believe your privacy rights have been violated, you can file a written complaint with the Privacy Officer, Lois Jordan, or with the secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Examples of Disclosures for Treatment, Payment, and Health Operations

We will use or disclose your health information for treatment. 

For example: Information obtained by a counselor or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your counselor will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the counselor will know how you are responding to treatment. 

We will also provide your counselor or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from this facility. 

We will use or disclose your health information for payment. 

For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. 

We will use or disclose your health information for regular health operations. 

For example: Members of the treatment staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. 

We will use or disclose your health information when required or otherwise permitted by law in so far as the use or disclosure complies with and is limited to the relevant requirements of such law.

For example: Members of the treatment staff are required to report child abuse and neglect to the authorities.

Other Permitted or Required Uses and Disclosures

Business associates: Information may be disclosed to business associates under a written agreement requiring the business associate to protect the information. Business associates are entities that assist with or conduct activities on behalf of Solutions, including organizations that provide legal, accounting, administrative, and similar functions.

Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care.

Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Marketing: We may contact you to provide alumnus activities, guest speaker meetings, or information about treatment activities or other health-related benefits and services that may be of interest to you. Any written marketing communication must be sent in an envelope showing only the address of the sender and recipient must include Solutions' toll-free number. If you choose not to receive further communications, Solutions must remove your name from the distribution list within five days.

Fundraising: Demographic information and dates of service may be disclosed to business associates (under an agreement) for Solutions' own fundraising under certain circumstances. Client authorization is required for all other uses and disclosures.

Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Law enforcement: We may only disclose your health information under a special court order meeting the specific requirements of 42 CFR. A subpoena or routine court order is not sufficient.

Reporting crime: No authorization is required to report crime (or threat of crime) on premises or against program personnel. Information is limited to circumstances, name and address, last known whereabouts.

Public health: Information may be disclosed to report cause of death as required by law; report child abuse and neglect as required by law; and to medical personnel of the FDA who assert reason to believe the health of an individual may be threatened by error in manufacture, labeling, or sale of product, and that information will be used exclusively for notifying clients and physicians of potential dangers. These disclosures must be made in such a way that the individual is not identified as a substance abuse client.

Regulatory activities: Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more clients, workers or the public.



I understand that as part of my healthcare, SOLUTIONS OUTPATIENT SERVICES ("Solutions") originates and maintains health records describing my health history, symptoms, evaluations and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals.

Solutions' Notice of Privacy Practices provides specific information and thorough description of how my personal health information may be used and disclosed. I have been provided a copy of or access to the Notice of Privacy Practices and understand that I have been provided with a copy of the Notice and been given an opportunity to review the Notice prior to signing this consent. Before implementation of the revised Notice of Privacy Practices, the revised Notice will be mailed to me if I provide my address below. I understand that I have the right to restrict the use and/or disclosure of my personal health information for treatment, payment, or healthcare operations and that Solutions is not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that Solutions has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing.

  I request the following restrictions on the use and/or disclosure of my personal health information.
  Solutions agrees to comply.
  Solutions disagrees to comply. Explain _________________________________________________________

I further understand that any and all records, whether written, oral or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law.

I have been provided and have received Solutions' Notice of Privacy Practices dated ______________.

_________________________________________          ___________________
Signature of Client or Legal Representative                        Date

_________________________________________          ___________________
Signature of Client or Legal Representative                        Date

_________________________________________          ___________________
Witness                                                                                Date

I request that changes to the Notice of Privacy Practices be sent to me at this address: